1. David C Koronkiewicz, D.O. IU Goshen Orthopedics and Sports Medicine
The Limping Child
David C Koronkiewicz, D.O.
IU Goshen Orthopedics and Sports Medicine
I0A 30th Winter Update

2. Definition Limp = Asymmetry Joint - Range of motion Bone - Deformity
Pain
Control

3. The Limping Child
Diagnosis
Mechanism

4. The Limping Child Pitfalls Being misled by the parents’ analysis
Always a leg length discrepancy
Being misled by the patient’s complaint
Hip problems can case knee pain
Complaints of pain

5. The Limping Child AGE Pitfalls COMPLAINS 5 LIMPS
NEWBORN
INFANT
TODDLER
CHILD
PRE-TEEN
TEENAGER
ADULT
Pitfalls
Being misled by the parents’ analysis
Always a leg length discrepancy
Being misled by the patient’s complaint
Hip problems can cause knee pain
Complaints of pain
COMPLAINS 5
LIMPS

6. The Limping Child Causes of limp -Physical exam
Joint - Range of motion
Bone - Deformity
Pain
-Hip
Control
-Physical exam
-X-ray
-‘Antalgic’ gait
-Abductor lurch

7. Differential Diagnosis of the Acutely Limping Child
Tumor
Spinal cord tumors
Tumors of bone
Benign: osteoid osteoma, osteoblastoma
Malignant: osteosarcoma, Ewing's s sarcoma
Lymphoma
Leukemia
Inflammatory
Juvenile rheumatoid arthritis
Transient synovitis
Systemic lupus erythematosus
Trauma
Fracture
Stress fracture
Toddler's fracture
Soft tissue contusion
Ankle sprain
Infection
Cellulitis
Osteomyelitis
Septic arthritis
Lyme disease
Tuberculosis of bone
Gonorrhea
Postinfectious reactive arthritis

8. Differential Diagnosis of the Acutely Limping Child
Neurologic
Cerebral palsy, especially
mild hemi paresis
Hereditary sensory
motor neuropathies
Congenital
Developmental dysplasia of the hip
Sickle cell
Congenitally short femur
Clubfoot
Developmental
Legg-Calvé-Perthes disease
Slipped capital femoral epiphysis
Tarsal coalitions
Osteochondritis dissecans (knee, talus)

9. Differential Diagnosis of the Acutely Limping Child by Age
All Ages
Septic arthritis
Osteomyelitis
Cellulitis
Stress fracture
Neoplasm (including leukemia)
Neuromuscular
Toddler (ages 1-3)
Septic hip
Developmental dysplasia of the hip
Occult fractures
Leg-length discrepancy

10. Differential Diagnosis of the Acutely Limping Child by Age
Child (ages 4 to 10)
Legg-Calvé-Perthes disease
Transient synovitis
Juvenile rheumatoid arthritis
Adolescent (ages 11-16)
Slipped capital femoral epiphysis
Avascular necrosis of femoral head
Overuse syndromes
Tarsal coalitions
Gonococcal septic arthritis

11. The Limping Child
Too much to cover
Hip
Best Bets
Age

12. The Limping Child Age 1 – 3 years Age 3 – 6 years Age 6 – 10 years

13. The Limping Child: Age 1 – 3
Best Bet
DDH
Developmental Dysplasia of the Hip
CDH
Congenital Dislocation of the Hip

14. The Limping Child: Age 1 – 3 DDH
Physical findings
Girl
Asymmetrical skin folds
Limited abduction

15. The Limping Child: Age 1 – 3 DDH
Physical findings
Short leg
Pistoning
Ortolani’s sign
Barlow’s sign

16. The Limping Child: Age 1 – 3 DDH
Barlow & Ortolani Tests
The Limping Child: Age 1 – 3 DDH
Feel Clunk
Not hear click !
Ortoloni
Barlow
( rollout the barrel)

17. The Limping Child: Age 1 – 3 DDH
X-ray findings
Delayed appearance of ossific nucleus
Small ossific nucleus
Dysplastic acetabulum
Proximal displacement of femur 42 22

18. The Limping Child: Age 1 – 3 DDH
Pavlik Harness
Check at 3 weeks to confirm reduction
Adjust position every 1-2 weeks
Continue until the hips are clinically and radiolographically normal
Treatment
0 – ½: Pavlik harness
½ – 1½: Closed reduction, cast
1 ½ - 5 or 8: Open reduction, pelvic osteotomy
Older: Leave dislocated

19. The Limping Child: Age 3 – 62 s
Best Bet
Transient synovitis
Septic arthritis
Flu
Tonsillitis

20. The Limping Child: Age 3 – 6
Transient synovitis
Child refuses to walk
Movement of hip is painful
May have fever
Moderately elevated WBC
Lasts a few days
Disappears without treatment

21. Transient Synovitis Benign, self-limited disorder
Associated with recent URI in 32-50% of children
30-40% of all non-traumatic limps
Sterile inflammation causing joint effusion
Lasts 2-7 days without intervention
Male:Female is > 2:1
Ages 2-6 (average 4)

22. Transient Synovitis Sudden onset of hip pain
Don’t forget knee pain!!
Afebrile/low-grade fever (<38.5)
Usually able to ambulate with a limp
Antalgic gait
Hip is flexed and externally rotated with mildly decreased ROM
5% bilateral presentation
25% with unilateral presentation with effusion on contralateral hip by ultrasound

23. Transient Synovitis Laboratory Evaluation WBC count <12,000
Mildly elevated ESR (<40); CRP (<2)
X-Ray
Joint space widening
Discrepancies >2mm between sides
Ultrasound:
Joint effusion and/or synovial swelling giving an increase in the synovial capsular complex distance
Distance btwn the posterior surface of the anterior fibrous joint capsule and the anterior bony surface of the femoral neck
Bilateral joint effusions in up to 25% of cases of asymtpmatic contralateral hip
J Bone Joint Surg 1999; 81:1662; J Bone Joint Surg 2006; 88A:1253

24. The Limping Child: Age 3 – 6
WIDENED JOINT SPACE
Septic arthritis
Child refuses to walk
Movement of hip is painful
May have fever
Elevated WBC
Progressively sicker
Progressive joint destruction

25. Transient Synovitis

26. Transient Synovitis Treatment Self-limited after 2-7 days Bed rest
Ibuprofen
Decreased pain by 2.5 days Vs Placebo
Mean duration of pain
ibuprofen: 2 days
placebo: 4.5 days
80% of all patients with resolution by 7 days
Annals of Emergency Medicine 2002; 40:3:297

27. Transient Synovitis Prognosis Generally good
Questionable association with long term increased risk for developing Legg-Calve-Perthes disease (1-2%)
Recurrance in 4-15% have been reported

28. Septic Arthritis Medical Emergency
Single most important prognostic factor for a good outcome is early treatment!!!
Direct entry of bacteria into the joint
S/p puncture injury; hematogenous; contiguous
Hematogenous osteomyelitis spread is most common in neonates/infants
Blood vessels traverse from the metaphysis to the epiphysis in infants. Physis formation disrupts this connection
>50% of neonates with osteomyelitis have associated septic arthritis

29. Septic Arthritis Most common organism: Staph aureus
Neonates: group B strep; gram (-) bacilli
Adolescent: Neisseria gonorrhoeae
Sickle Cell Disease: Salmonella
Acute inflammatory response
TNF-alpha, IL-1, proteases: destroy the articular cartilage
Continues after eradication of the bacteria
Associated with high risk of avascular necrosis of the hip
Joint pressure compressing the blood vessels supplying the cartilage and femoral head

30. Septic Arthritis
Fetal breech presentation predisposes to sebsequent development of septic arthritis of the hip. The Pediatric Infectious Disease Journal 2005; 24:
Propensity for group B strep osteomyelitis to involve the right proximal humerus in infants
J Pediatrics 1978; 93:

31. Septic Arthritis Usually in previously healthy children < 5 years
Early peak in the first months of infancy
1/3 of pts with URI’s within the past month
Acute painful joint with erythema, warmth, swelling and pain on passive movement (knee)
Up to 8% is multifocal
Fever > 38.5
Usually unable to bear weight
Antalgic gait present if able to bear weight
Knee is most common joint
Hip, ankle, wrist, elbow, shoulder

32. Septic Arthritis
Septic arthritis of the hip DOES NOT present with erythema, warmth or swelling
Hip is flexed in external rotation and abduction
Relieves intracapsular pressure
Infants often present with paradoxical irritability, malaise and/or pseudoparalysis of the affected limb
Gentle motion aggravates Vs soothes
Do not necessarily have fevers

33. Septic Arthritis Elevated WBC, ESR, CRP
CRP accurate negative predictor of disease
Inc. dramatically within 6 hrs after a trigger
Peaks on D#2 and resolves by D# 7-10
Blood Culture positive in 40-50%+

34. Septic Arthritis Aspiration of the hip: definitive diagnosis
Cloudy, turbid
WBC count >50,000; predominately neutrophils
Glucose levels < ½ of serum levels
50% with positive gram stain
50-70% with positive culture
Specific media needed to isolate N. gonorrhoeae

35. The Limping Child: Age 3 – 6 Septic Arthritis
Bacteria
White cells
Enzymes
Enzymes
Destroy cartilage
Irreversable joint damage

36. Septic Arthritis Radiographic Findings
Xray findings seen 10 days into disease
Osteopenia, marked joint space loss, soft-tissue swelling
Ultrasound (both hips)
Visualize joint effusions at onset
CT/MRI
Good to r/o abscesses and assess for concurrent osteomyelitis

37. Septic Arthritis Antibiotic Treatment
Age
Organism
Antibiotics
<12 mos
staphylococcus, group B streptococcus, and gram-negative bacilli
1st generation cephalosporin
6 mos. to 5 yrs
S. aureus,S. pneumonae, Group A streptococcus, H influenzae
2nd or 3rd generation cepahlosporin
5-12 yrs
S. aureus
1st generatin cephalosporin
12-18 yrs.
N. gonorrhoeae, S. aureus
oxacillin/cephalosporin

38. Septic Arthritis Treatment IV antibiotics times 2-4 weeks
Can change to PO if clinically imp with normalizing ESR/CRP on IV therapy, but NOT with septic arthritis of the hip
Joint drainage
Low-dose dexamethasone for 4 days
Pediatric Infectious Disease Journal 2003;22:

39. The Limping Child: Age 3 – 6 Septic Arthritis
Treatment
Kill the bacteria
Antibiotics
Eliminate the white cells
Incision and drainage
Don’t delay
48 hour window

40. Septic Arthritis Prognosis Good outcome Poor outcome
Initiation of treatment within 4 days of symptom onset
Poor outcome
Initiation of treatment after 5 or more days
Severe joint destruction: osteonecrosis
Lifelong joint pain increased after activities
Decreased ROM
Leg length discrepancies
Lifelong limp

41. Septic Arthritis Vs Transient Synovitis
Caird et al. Journal of Bone and Joint Surgery. 2006
CHOP
Prospective study
WBC> 12,000/mm3
ESR> 40 mm/hr
CRP> 2 mg/dL
Temp> 38.5 Oral
Refusal to bear weight
Kocher et al. Journal of Bone and Joint Surgery. 1999
Boston Children’s
Retrospective study
WBC> 12,000/mm3
ESR> 40 mm/hr
Temp > 38.5 Oral
Refusal to bear weight

42. Septic Arthritis Vs Transient Synovitis
Individual Factor results:
No child with a temperature >38.5 was found to have transient synovitis
CRP > 2mg/dL was the only independent risk factor strongly associated with septic arthritis after backward elimination
86% of patients with ESR < 40 mm/hr had transient synovitis
71% of patients with CRP < 2mg/dL or WBC < 12,000/mm3 had transient synovitis

44. The Limping Child: Age 3 – 6 Transient Synovitis vs. Septic Arthritis
How to tell the difference?
Four predictors
History of fever
Refusal to weight-bear
ESR > 40 mm/hr
WBC > 12,000
If in doubt
Review in 12 hours
Do incision and drainage!
Kocher, Kasser, et al. JBJS 86-A: 1629, 2004

45. The Limping Child: Age 3 – 6 Septic Arthritis
The Worst Scenario
Destruction of articular cartilage
Destruction of femoral head
Destruction of femoral neck

46. The Limping Child: Age 3 – 6 Septic Arthritis

47. The Limping Child: Age 6 - 103
Best Bet
Legg-Calvé-Perthes Disease

48. Legg-Calve-Perthes Disease
Avascular necrosis of the capital femoral epiphysis.
Hypothesized to arise from repeated interruptions of the vascular supply to the femoral head.
Male:Female is 4:1.
Most common between 4-10 years of age.
10% of cases are familial
Present with limp (most common presentation) with decreased internal rotation of the hip.

49. Legg-Calve-Perthes Disease
Positive Trendelenburg test.
Pelvic tilt (affected side is lower) when standing on the affected leg.
Pain can radiate to hip, thigh or knee.
often insidious and can lead to disuse of affected limb

50. The Limping Child: Age 6 – 10 Perthes Disease
Physical findings
Boy
Limp
Antalgic gait
Pain with passive motion
Limited abduction
Positive Trendelenburg sign

51. The Limping Child: Age 6 – 10 Perthes Disease
X-ray findings
Perhaps nothing
MRI
Irregular consistency
Flattening
Lateral bump/ridge
Lateral hinging

52. Legg-Calve-Perthes 4 Distinct Radiographic Stages
Synovitis/Necrosis: Initial joint space widening and irregularity of the physis. Ischemia of the epiphysis resulting in dead bone. Ave age 5.6 years
Fragmentation. Fracturing of the weakened demineralized epiphysis. Epiphysis may collapse resulting in a shortened limb. Ave age 6.1 years

53. Legg-Calve-Perthes 4 Distinct Radiographic Stages (cont.)
Re-ossification. Begins at the margins of the epiphysis. Ave age 7 years
Remodeling. Newly formed head is soft. At risk for poor prognosis if not allowed to heal. Ave age 9.1 years
MRI better at detecting early disease

54. Legg-Calve-Perthes
                                                                                           
radiology.creighton.edu/.../case19/index.htm

55. Legg-Calve-Perthes

56. Legg-Calve-Perthes
Revascularization phase
Avascular phase

57. Legg-Calve-Perthes Bilateral disease in up to 24% of cases
Contralateral hip usually involved within 3 years of disease onset, but can present after 5 years
1/3 of cases present with BIL hip involvement in the same stage
Questions the previously held belief that the disease in one hip puts the contralateral hip at risk
Retrospective review
J Pediatric Orthopaedics 2002; 22:
Girls more likely to have bilateral disease

58. Legg-Calve-Perthes Treatment 50% recover without treatment
Maintaining containment of the femoral head within the acetabulum
Abduction splints/casts and non-weight bearing state
Surgically with an osteotomy of the proximal femur

59. Legg-Calve-Perthes Prognostic factors
Better prognosis if child presents before 6 years of age: extended period of time allowed for remodeling
Obesity is associated with a poor prognosis
Extent of epiphyseal necrosis present: <50% necrosis with better outcome
Bilateral disease not associated with a worse prognosis

60. The Limping Child: Age 6 – 10 Perthes Disease

61. The Limping Child: Age 6 – 10 Perthes Disease
50% need a Total Hip by age 50

62. Legg-Calve-Perthes
Natural history of early onset LCP disease. These radiographs were taken at age 2, 3, 5, 8 and 15 years. Courtesy of "Fundamentals of Pediatric Orthopedics", 2003, Lippincott Williams & Wilkins ©

63. The Limping Child: Age 10 – 14
Best Bet
Slipped Capital Femoral Epiphysis (SCFE – sciffey)

64. Slipped Capital Femoral Epiphysis
Non-inflammatory condition
Femoral head displaced posteriorly from the femoral neck
Age of onset: years
Overweight boys (1.5M:1F)
African Americans>whites, hispanics

65. Slipped Capital Femoral Epiphysis
Associated with endocrinopathies (growth hormone deficiency) in 8%
If presenting under 10 years of age, hx of short stature or hypogonadism: endocrine evaluation

66. Slipped Capital Femoral Epiphysis
Preceding history of trauma with acute pain/limp
Subacute or chronic pain with insidious onset that can be referred to the hip or knee
Pain increased with physical activity

67. Slipped Capital Femoral Epiphysis
Examination
Limb is held slightly flexed and externally rotated
Often unable to fully flex hip
Limited internal rotation and abduction of the hip
Limited passive ROM secondary to pain
Bilateral in up to 30%
Positive Trendelenburg test

68. Slipped Capital Femoral Epiphysis
Radiography
X-ray of both hips
Mild, moderate or severe depending on degree of femoral head slip compared to the femoral head diameter (<1/3=mild; 1/3-2/3=moderate; >2/3=severe)

69. Xray Findings Displacement of neck on head Mainly anterior
Somewhat superior
Decreased projected femoral head height
Chronicity
Inferior new bone
Superior rounding off of metaphysis
Curved neck

70. Slipped Capital Femoral Epiphysis
Klein’s line

71. Slipped Capital Femoral Epiphysis

72. Slipped Capital Femoral Epiphysis

73. Slipped Capital Femoral Epiphysis
                                                            

74. The Limping Child: Age 10 – 14 SCFE
Always get a frog lateral view
Always check the other side

75. CastroAP

76. The Limping Child: Age 10 – 14 SCFE
Pediatric orthopaedic surgeons
See 6 per year
General orthopaedic surgeons
See 1 every 6 years
Same as fixing a fracture

77. The Limping Child: Age 10 – 14 SCFE
Classification
Acute or chronic
Acute on chronic
Stable or unstable
Severity of displacement
Slip angle
Bilaterality
10 – 15% at presentation

78. Useful Classification
Stable
Walks in
Unstable
Wheels in
No reduction One screw
Bone in one piece
Slow plastic deformation of the growth plate
Closed reduction Two screws
Bone in two pieces
Physeal fracture

79. Slipped Capital Femoral Epiphysis
Treatment
Non-weight bearing with crutches to prevent further slip
Surgical fixation
Prognosis
Usually good prognosis
Increased risk of subsequent acute chondrolysis or avascular necrosis of the hip

80. Fixation SCFE

81. Fixation SCFE

82. The Contralateral Hip Out of 100 patients:
10 are bilateral at presentation
10 will slip on the other side later
5 will have painless slips on the other side

83. Follow-up for Bilaterality
Follow radiolographically
Every three months
For 18 months
Screw removal- controversial

84. Best Bets The Limping Child Age 1 – 3 years - DDH
Age 3 – 6 years - Septic arthritis
Age 6 – 10 years - Perthes Disease
Age 10 – 14 years - SCFE
Best Bets

85. THANK YOU